In this article we will give an account of the introduction of evidence-based practice (EBP) in Swedish social work. The Swedish development may serve as an example of what happens when the process is driven by bureaucracy with a strong public funding/back-up rather than by the academy. This is not to say that the Swedish case is unique, but rather that problems and controversies that are well established on the international arena are in Sweden framed in a very particular context. The most far reaching efforts to implement EBP in Swedish social work have been carried out by central bureaucracy. The introduction of EBP may be depicted as a top-down guideline project, with randomized controlled trials as the gold standard. Shortage of evidence paired with political pressure to implement EBP has to a certain extent also brought about dissolution of the basic concept. The article concludes with an elaborated assessment of how current conceptions of EBP relates to professional and contextual conditions of Swedish social work practice. We also address the issue of how to establish what adequate and valid evidence is by suggesting an approach that deviates from predominant evidence hierarchies and polarized extremes.

In this article we scrutinise three prominent guidelines on psychosocial interventions for alcohol problems. We pay special attention to how congruent the guidelines are in terms of the interventions recommended, and the processes used in order to identify and rank the “evidence” underpinning these recommendations.

Data

The analysed guidelines are: 1) Practice Guideline for the Treatment of Patients with Substance Use Disorders, American Psychiatric Association (2006); 2) Alcohol-Use Disorders. The NICE Guideline on Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence (2011), National Collaborating Centre for Mental Health, UK; 3) Guidelines for the Treatment of Alcohol Problems, Australian Government, Department of Health and Ageing (2009). The purpose is not to review the three guidelines as such, but to study them as an example of the production of evidence. All report to be based on “best available evidence”, so the guidelines were compared both regarding the actual recommendations and the guideline production procedures and differences in these procedures with related consequences.

Results & CONCLUSIONS

Prestigious organisations in different national contexts have reached divergent conclusions about evidence-based practice and the quality of the scientific studies underpinning these conclusions. Differences in the guidelines regarding interpretations, limitations and grading illustrate the difficulties with the dilemmas of sensitivity (to include factors that are significant for how a psychological intervention is to be judged) and specificity (that irrelevant studies are cleared off) in the recommendations presented.

In the discussions for the future DSM-5, the Substance-Related Disorders Work Group has been addressing “addiction-like” behavioral disorders such as “Internet addiction” to possibly be considered as potential additions for the diagnostic system. Most research aiming to specify and define the concept of Internet addiction (or: Excessive/Compulsive/Problematic Internet Use—PIU), takes its point of departure in conventional terminology for addiction, based in established DSM indicators. Still, it is obvious that the divide between characteristics of addiction and dimensions of new lifestyles built on technological progress is problematic and far from unambiguous. Some of these research areas are developing from the neurobiological doctrine of addiction as not being tied to specific substances. The concept of “behavioral addictions”, based on biological mechanisms such as the reward systems of the brain, has been launched. The problems connected to this development are in this study discussed and reflected with data from a Swedish survey on Internet use (n = 1,147). Most Swedes (85%) do use the Internet to some degree. The prevalence of excessive use parallels other similar countries. Respondents in our study spend (mean value) 9.8 hours per week online at home, only 5 percent spend more than 30 hours per week. There are both positive and negative social effects at hand. Many respondents have more social contacts due to the use of Internet, but there is a decline in face-to-face contacts. About 40% of the respondents indicate some experience of at least one problem related to Internet use, but only 1.8% marked the presence of all problems addressed. Most significant predictors for problem indicators, except for age, relate to “time” and time consuming activities such as gaming, other activities online or computer skills.

The body of Internet addiction research articles has grown rapidly during the last years. Critics claim that the bulk of this research is more confirmatory than scrutinizing, in spite of weak evidence for the label of addiction. A study on excessive Internet use in Sweden has been cited repeatedly in Internet addiction studies. The present study takes a closer look at these citations and combines the presentation with a systematic review of methods and theoretical approaches in Internet addiction studies, published between January 2000 and July 2013.

A crucial, but under-appreciated, aspect in experimental research on psychosocial treatments of substance use disorders concerns what kinds of control groups are used. This paper examines how the distinction between different control group designs has been handled by the Cochrane and the Campbell Collaborations in their systematic reviews of psychosocial treatments of substance abuse disorders.

Methods

We assessed Cochrane and Campbell reviews (n = 8) that were devoted to psychosocial treatments of substance use disorders. We noted what control groups were considered and analysed the extent to which the reviews provided a rationale for chosen comparison conditions. We also analysed whether type of control group in the primary studies influenced how the reviews framed the effects discussed and whether this was related to conclusions drawn.

Results

The reviews covered studies involving widely different control conditions. Overall, little attention was paid to the use of different control groups (e.g. head-to-head comparisons vs. untreated controls) and what this implies when interpreting effect sizes. Seven of eight reviews did not provide a rationale for the choice of comparison conditions.

Conclusions

Cochrane- and Campbell reviews of the efficacy of psychosocial interventions with substance use disorders seem to underappreciate that use of different control group types yields different effect estimates. Most reviews have not distinguished between different control group designs and therefore have provided a confused picture regarding absolute and relative treatment efficacy. A systematic approach to treating different control group designs in research reviews is necessary for meaningful estimates of treatment efficacy.

Research indicates that a number of psychosocial interventions are effective for reducing behavioural problems in youth. These interventions are now often included on best practice lists aiming to facilitate informed treatment choices among practitioners. However, analyses in neighbouring research areas have highlighted serious shortcomings in how primary studies are analysed and how studies are synthesised in research reviews. This study took a closer look at the evidence of efficacy for psychosocial interventions that aim to reduce behavioural problems in youth, as shown in systematic research reviews by the Cochrane and the Campbell Collaborations (n = 8). The findings suggest a bias towards overemphasising the efficacy of the interventions in several reviews, an over-confidence in the validity of the findings in some reviews and, overall, a somewhat uncertain evidence base for the efficacy of the interventions. Systematic reviews are crucial for summarising research but more attention to methodological issues may be needed in this area.

We explore how four evidence-producing organisations in the US go ahead when they rate the evidence base for psychosocial interventions, using the Incredible Years programme as our case study. The findings demonstrate variation in the procedures and resulting evidence claims across the organisations, with some organisations being strict and some being permissive. The presence of such conflicting practices highlights central challenges for the evidence-based practice framework and its ambition of obtaining uniform evidence statements. We conclude that practitioners and policy makers should be aware of such variation in order to be able to make informed decisions regarding which programmes to use.